‘The most supportive service I have worked in’: how a transition team is transforming lives

Turning 18 is an important milestone in any young person’s life. But for young people who need social care, it also marks the transition point between children’s and adults’ services – a process that has traditionally been a challenge in many councils.

From the age of 14, the Preparing for Adult Life (PfAL) team tries to identify those young people known to Norfolk children’s services or education providers who are likely to need social care when they officially become adults.

For Sasha, the PfAL team manager, beginning the transition early is crucial.

“Starting early really enables us to get to know the young people and really get to know what’s important to them,” she says. “We’re very person-centred so we spend a lot of time, in a very light touch way that’s the most appropriate to that young person, thinking about our PfAL outcomes, which are around employment, education, social skills, health and independence.

Sasha, PfAL team manager

“Being 18 is really scary for some of our young people and also should be really exciting, so it gives us the chance to get to know the anxieties and get to know what worries them and help fix that.”

After a self-commissioned review into Norfolk’s transition service in 2019, it was clear that something had to change. Many young people were being assessed after their 18^th birthday and, as funding from children’s services stops at 18, there was not support in place for their adult life.

More information sharing between children’s and adults’ services and the need for earlier intervention was identified as necessary. In early 2020, under the umbrella of adult social services, PfAL was born.

Working with PfAL

Joanna, a practice consultant in the adult social services learning disabilities team, has been with Norfolk for most of her career and works closely with the PfAL team.

“As a receiving team, we know who’s coming up because of PfAL and we have more time to prepare. It’s brilliant not having that cliff edge at 18. You need to have that future focus in children’s services, you need to be considering the decisions you’re making for a child at 16 and what’s that going to mean to them when they’re 18.

“It’s no good putting them in a supported placement that’s going to stop – as funding will stop at 18 – so we need to be working towards goals and be realistic about what is likely to be provided.

“Families have talked about fights they’ve had historically to get adult services. PfAL bridges that gap for families and practitioners. You’re getting in early and you’re preventing delay, stress, confusion and anxiety for the person and their family as they’ve got someone holding their hand through that and they know what to expect,” explains Joanna.

Millie* was 17 when her GP referred her to the council for assistance. She had a range of challenges such as autism, epilepsy and some mental health problems.

PfAL assessed her to ensure that, when she reached 18, there was sufficient support in place and then consulted with Joanna’s team to develop Millie’s care and support plan.

After seeing a child psychologist, PfAL was able to place Millie in an enablement scheme. Joanna’s team works closely with the scheme provider to ensure suitable people can access it.

The programme usually lasts two years and helps young people to become independent adults, teaching them how to shop, cook, budget and acquire other life skills.

As she is doing so well, Joanna predicts Millie, who is nearly 20 now, will move into her own independent flat in the community after she moves through the enablement program.

“She’s doing amazingly well! As practitioners it’s so rewarding – that’s what we come to work for,” says Joanna.

What are the PfAL team doing differently?

Roger Allen, service manager of PfAL, was given the task of building and managing the team from the ground up.

“There’s a really good emphasis that we have got on professional development and there is supportiveness within the team – it’s probably the most supportive service I’ve worked in to be honest,” says Roger.

Roger Allen, PfAL service manager

The team started off with 10 practitioners and assistant practitioners but has since grown to 15 workers with a mix of skills.

As well as qualified practitioners from children’s and adults’ services backgrounds, assistant practitioners who deal with less complex cases bring their own skillsets to the team.

For example, the PfAL team includes practitioners with a background in young people’s career guidance and youth work, which enriches the skills and knowledge in the service.

There is emphasis on daily communication, weekly case discussions and regular reflective practice and supervision. A weekly forum enables practitioners to get together and talk about what is troubling them, share knowledge with each other and celebrate the wins.

Michaela, a newly qualified social worker in the PfAL team, can testify to this focus on staff development.

“PfAL are quite forward thinking – if I see training on the system that looks like it will be helpful, I will just book myself on it. It’s very much encouraged”, she says.

“Recently, I’ve had to learn about neurological disorders and therapies as I have a few cases with complex mental health and cases of epilepsy that need to be managed. I just did epilepsy training this morning!

“I’m not a health professional but I need to have conversations with psychologists, psychiatrists, epilepsy nurses, GPs etc so I need that background knowledge.”

Michaela is also working towards a master’s in advanced social work at the University of East Anglia. As well as funding the degree, Norfolk gives Michaela time off to attend classes.

“I love social care,” says Michaela. “I did the social work training and have not looked back and I must say I have felt supported by Norfolk throughout.”

Michaela, PfAL social worker

 A multi-agency approach

Roger believes that taking a more holistic, multi-agency approach has improved the lives of the young people Norfolk serves. Working collaboratively inside and outside the team in a supportive way has helped PfAL flourish, he says.

“What the PfAL service has brought to Norfolk is a lot of consistency, a lot of clarity around how transition into adult social care works. We are the single point of access into adult social care so we take referrals under the age of 18. We are well known in Norfolk across children’s services, across SEND, health colleagues and many other places,” says Roger.

Roger, along with his team, chairs and co-ordinates regular network meetings with other service providers in the locality.

Strengthening relationships with local charities, schools, colleges, mental health services, NHS providers and others is at the heart of PfAL’s philosophy; the idea being that different groups get to know that each other exist so they can reach out to them when they need to.

“There is a real focus on looking at the benefits of working with other professionals. We’ve got that culture and approach where everyone understands the importance of doing that – as you cannot work in isolation or work in silos.

“You’ve really got to work in combination with other relevant people and sometimes, when you have tricky situations, which you inevitably do in any kind of social work team, I think we’re really good at bringing everyone together and bringing them round the table,” says Roger.

PfAL has received many compliments from families, colleagues and other organisations. One parent wrote: “I would like to say thank you for all your help over the past 18 months, without your assistance we would never have navigated our way through the very complex move from children’s services to adult provision.”

*Name changed for confidentiality

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